Nomination Submission

I. NOMINEE

Name of institution (s) or individual (s) with title, position and affiliation. *

II. MAILING ADDRESS

Please check the box *

Office Home

Address *

City *

Country *

Postal Code *

Phone *

Fax *

E-Mail *

Other

III. JUSTIFICATION FOR NOMINATION

III.1 Has the awardee made a scientific contribution of internationally recognized standards which has been shown to be of important benefits to a large number of the people of the world, transcending notional boundary? *

III.2 Has the awardee made successfully an application of a body of scientific knowledge to the benefits of a large number of the people of the world, transcending national boundary? *

IV. STATEMENT IN SUPPORT OF NOMINATION

Please provide details of the best or the most significant contribution of the candidate.

IV.1 Give objective evidence of the impact of the medical research, health research or health service to a large number of people. *

IV.2 Would you care to give the name of other worthy candidate in the same field as the nominee? (optional)

V. AWARDS AND HONOURS RECEIVED

AWARDS AND HONOURS RECEIVED

VI. EDUCATIONAL BACKGROUND

EDUCATIONAL BACKGROUND

VII. POSITIONS OCCUPIED

List the present position (s) and the previous position (s) with dates and durations together with names and addresses of employers. *

VIII. PUBLICATIONS

List all important publications. Submit reprints or copies of important ones (not more than five). Attach English abstracts or English translation in case publications are not in English.

IX. NOMINATED BY

Last name *

First name *

Middle initial

Title *

Position *

Address *

City *

Country *

Postal Code *

Phone

Fax

E-Mail *

Other

X. Attachment

Attachment File (PDF or ZIP)

Note

Please give full information on the category III & IV. Well prepared statements which are verifiable will be of value to the nominees and to the selection commitees.

Please send not more than two letters of references, that could add more information and justification for the nomination, along with the nomination.

In case the nominee is an institution, please attach documents on the history, status and key officials of the institution (s). Use additional paper for each category for information as necessary.